California’s Obamacare exchange enrolled the most people in the nation, but San Francisco hospitals and doctors have yet to see an uptick in patients, reports the San Francisco Business Times.

Indeed, health industry analysts expected that “pent-up” demand for overdue procedures and tests would correspond with an increase in doctor visits by the newly-insured. But so far that is not happening.

Health Access California Executive Director Anthony Wright hypothesized that perhaps people do not know how to use their new insurance.

“Some of the new folks may not know how to use the health system yet,” said Wright.

Another explanation may be that the newly-insured are only now learning what high deductibles mean. A study last year in the Journal of Health Economics found that just 14% of individuals who have health insurance could accurately answer four basic questions about policy terminology, including what a “deductible” is.

Another possible explanation is that the vast majority of people who have signed up for Obamacare already had insurance. Indeed, Obamacare canceled five million individuals’ insurance policies, thereby forcing them to either sign up for Obamacare, seek coverage elsewhere, or remain uninsured.

Finally, some Californians are learning that Obamacare’s narrow networks – extreme restrictions of access to doctors and hospitals – may mean that nearby doctors and hospitals do not accept their Obamacare plans. As Breitbart News reported, some California plans force patients to drive over 100 miles to find the nearest doctor who will accept their Obamacare insurance.

Obamacare will cost U.S. taxpayers $2.6 trillion over the next ten years.